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Form Prescribed by SICIle Board of AcCOWll8 Boyce VYIl1em&. MWlcl.. III -
RECEIPT
(J
GENERAL FORM NO. 852 tREY. .187)
DEPARTMENT OF COMMUNITY SERVICES
(},~b~ FUND
CARMEL IN.. ~') ~ ~ U 20 'D ~
RECEIVED FROM
THE SUM OF ~
ON ACCOUNT OF
N2 1614
$'2>II'SO''C:I~
,",?-, ~\
OLLARS
100
U,-J
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UTHORIZ 81aNATURE
PAYMENT TYPE & AMOUNT --
CASH CHECKS ~d'D~.O
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